Podcast 101 – Avoiding Resuscitation Medication Errors – Part I

Bryan Hayes

Today I am lucky to have the opportunity to interview Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors in the ED. Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.

Medication Errors during Resuscitations

It is extremely easy to make errors during resuscitations. (Resuscitation 2012;83(4):482-7) Also, read the review by EMLitofNote

TPA dosing in stroke and PE

No calculators or mental math should ever be involved with Resus medication administration. Our drip sheet project attempts to prevent this. These sheets are printed out for mixing and then taped to the infusion pumps.

Bryan had an error where a 1 mg dose was given IV for anaphylaxis. Patient developed ECG changes and troponin leak. He removed the 1 mg/mL vials and replaced them with the much more expensive EPIpens. Other solutions: premade pharmacy IM Syringes or just dispense with IM and give IV infusion for all patients.

Kanwar M. Ann Emerg Med 2010;55(4):341-4

Why are premix bags not readily available everywhere? – Bryan outsources for 6.25mg in D5W 250ml (25mcg/ml) and 2mg in D5W 250ml (6mcg/ml)

Insulin Issues

HyperK

What is the proper accompanying dose of D50 when giving insulin IVP for hyperkalemia?

– 10 units of regular insulin bolus, followed immediately by 50 mL of 50 percent dextrose (25 g of glucose) is inadequate! This regimen may provide a greater reduction in serum potassium since the potassium-lowering effect is greater at the higher insulin concentrations attained with bolus therapy. However, hypoglycemia occurs in up to 75 percent of patients treated with the bolus regimen, typically about one hour after the infusion. To avoid this complication, infuse 10 percent dextrose at 50 to 75 mL/hour or give 2 amps of D50 (50 grams) and ensure close monitoring of blood glucose levels.

Update: One of the commenters below asked for a reference for the up to 75% statistic. Took some time to track it down, but it is this article (PMID: 2266671). This article showed a markedly lower, but still worrisome percentage in gen pop. Most of those events were with the 1 amp regimen (PMID 22489323). This one showed an incidence of 13% (doi: 10.1093/ckj/sfu026).

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Ryan

Just a couple of points. My wife and I are both pharmacists at two different hospitals and have enjoyed the podcast for over two years. Regarding TPA, pharmacists at both of our hospitals are responsible for mixing TPA on stroke patients. Also of note supposedly the manufacturer’s of
TPA have told my wife’s hospital they will stop reimbursing for drug not used due to the high frequency of wasted drug at their hospital ( neither of us have ver hear it straight from the drug company but wanted to relay that possibility out to the audience.) Reference your site all the time and love following Bryan on Twitter.

I’m glad you commented on mcg/kg/min vs. mcg/min for adrenaline, noradrenaline, dopamine etc. I started my ICU life in New Zealand where we used mg/h for vasopressors and inotropes, without a weight adjustment. I then moved to NSW, Australia where all the hospitals I’ve worked in thus far use mL/h. However some hospitals use a 4mg/100mL concentration and others use a 6mg/100mL concentration. But wait, there’s more. Once you reach about 40mL/h we switch to “double strength” (8mg/100mL) and then “Quad strength” (16mg/100mL). While this increased concentration makes the nurse’s life easier, and I guess gives everyone an indication that the patient isn’t doing well, I think it has potential to cause problems one day. Having said that, the whole point of vasopressors and inotropes (and analgesics and sedatives for that matter) is that they’re titratable. The correct dose is “enough,” so to a degree the concentration doesn’t matter. After working in a new place for a couple of weeks, you figure out what the “average” dose is. The issue, as you stated, is when different units in the same hospital or district use different units of measure. Thanks for another great podcast. I’m not sure if you’ll talk about… Read more »

Great podcast. I’m curious on what your thoughts are on how pediatric resuscitation dosages play into this….in all the prehospital services I’ve worked for, meds are packaged according to standard adult doses, I’m assuming in part to help reduce medication errors. However, this leads to problems with the rare (thankfully) pediatric resuscitation…I’ve been involved either directly or indirectly with medication errors involving weight-based pediatric doses during these cases. I’ve been a proponent of ditching preloads for multi-dose vials to force providers to use weight-based math for all patients as a strategy to prevent these errors, based on the assumption that the more often you perform a task in less stressful situations the easier it is to perform. Does anyone’s institution use a similar pre-calculated sheet for pediatric doses or have any experience in dealing with this issue?

I wanted to point out a need for the 1:1000 vial of epinephrine. I think it may be different in other countries but racemic epinephrine is no longer available in Canada. For nebulized epinephrine for stridor, we occasionally need to give 5mg of 1:1000 epi.

Great session and I look forward to part II. Just a quick reference, if one goes to activase.com they can request tpa dosing cards for free. The cards have the info in columns and dosing is calculated across the window as you pull the inner card out finding the weight. We stick one in each of our stroke packets.

I think Joe Lex gives a pretty reasonable and believable explanation of drug shortages in AAEM lectures from 2013 – found it on emedhome, little more info than what Bryan says…

This avoiding errors podcast very timely.

Regarding Pedi aspect mentioned above – “The Broslow guy” is obviously way deep into this. Special program (for institutions) but also an app that is about 10 bucks for android device. Another – Pedistat – very slick – I am frequently double checking myself with both of these.

Can you please explain how giving insulin vs subcutaneous is different? I know IV has a shorter duration, but why does it not affect the glucose as much as giving subcutaneous? What is the reasoning behind this? Thanks!

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5 years ago

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LeighAnn

I’m asking the same question as Jeremy above.Maybe I just misunderstood how the question was proposed. I interpreted as though mechanism was different. I’ve searched and can’t find this anywhere. I was under impression subc was less accurate due to varying absorption compared to IV. Please enlighten me. Also, thanks for swinging through Columbus. Thoroughly enjoyed your forum! Thanks!

Jeremy and Leighann, glucose transporters are maximally filled at a dose of 1 units/kg/hr IV infusion. Anything beyond this is just wasted insulin from the glucose-lowering perspective. An IV push dose brings plasma levels way beyond this point and most of that insulin is wasted and the duration of action is much shorter than a sub-q dose that mirrors the IV infusion.

For Hyper-K however, you are trying to activate the Na-K-ATPase, which have a much higher requirement of insulin for maximal activation (i.e. maximal lowering of K).

Leighann–in the critically ill, an IV INFUSION, is considered to be more consistent than sq dosing. Not IV pushes of insulin.

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5 years ago

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LeighAnn

Thanks for the explanation!

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5 years ago

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Adam

Trying to find the source for the 1 unit/kg/hr statement and am having a hard time. I’m just now trying to convince my doctors in ER to switch to subcutaneous administration vs. IV. Thanks!

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5 years ago

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Mitch page

epi is pretty stable in syringes. I’m aware of a outdoor program that replaced epipens with prefilled syringes Here are two good papers on the topic.

This is a topic that interests me greatly and I’ve been seeking thoughts and opinions on a project I’ve been working on. It’s a “dynamic” PDF that uses JavaScript to automatically calculate drug dosages once a patient weight has been input. This particular prototype is designed for pediatric drug dosages, but there’s logic built in so it doesn’t exceed maximum doses (or minimum doses, in the case of Atropine) if you reach adult weights, and after selecting age range from a drop-down it automatically selects the proper Dextrose concentration as described in our protocols.

I know there are a few apps that have this functionality, but they don’t seem as customizable when dosing regimens, concentrations, and practices can change from place to place – or easily distributed. I figured it would also be convenient to print out after you input a weight, used as a customized medication dose sheet.

If anyone has the time, I look forward to any opinions you may have! Please feel free to e-mail me as well: michael.pieretti [at] bostonmedflight.org

Thanks for the kind words, I think it’s got potential. I’ll start throwing together an adult prototype for use at Janus General Hospital!

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5 years ago

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Paul Takamoto, Pharm.D.

Great write up by Bryan! Just as a precautionary point…insulin can bind to the surfaces of the IV bag and tubing- especially with conventional PVC material. This would not be so much an issue with insulin infusions for DKA patients where higher concentrations (100 units/100mL at our institution for adults) are used to titrate blood glucose. For hyperkalemia, I feel that shooting 10 units regular insulin into a D10 500 mL bag can have significant losses with a smaller unit amount of insulin per volume. By the time the bag is primed and infusing into the patient, we aren’t very sure how many units the patient has received. For that reason, I still prefer the insulin and dextrose 50% syringe combo.

Thanks for another great post Scott I have a late comment in favour of using IM adrenaline (or epi) in anaphylaxis. When these cases come in I let the nurse and resident scramble around trying to get in a hurried IV while I draw up 300-500mcg of 1:1000 adrenaline and give it IM. By the time the IV is in most patients are feeling better and the danger has passed. The can have a bit of fluid and some top up adrenaline I required. And in favour of 1:1000, the main thing I can think of is that it might be kinder when giving it to little toddlers IM. I think the nebulised adrenaline issue mentioned above is a stronger reason for keeping it. As for calling it 1:1000 rather than 1mg/mL. I am all in favour of doing away with that stuff. Ditto the 1% lignocaine and the misery of trying to do calculations with sodium from 0.9% or 3% to mmol/L. In our place (regional Australia) by the way, we use mcg/min for adrenaline and noradrenaline and mcg/kg/min for dobutamine. I have no idea why. Luckily I almost never order dobutamine so I am spared that. The mcg/min… Read more »

sure, no IV go IM. I’d like to see some legitimate studies demonstrating the benefits of nebulized adrenaline.

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5 years ago

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Steve Freriks

I am a pharmacist that has worked in the ED in Alberta, Canada for 10+ years now. I am catching up on these podcasts and I downloaded this one first, looking forward to the discussion with Brian D. Hayes. I have to say I was VERY disappointed that Brian generalized and blasted research where pharmacists were involved, stating, “anytime you are looking at a study like this where pharmacists are involved you know there is going to be a little bit of bias, because we are always looking for ways to increase our presence to add more positions and justify what we are doing….”, and “…it is hard to justify those salaries today…”. I take exception to those comments. In our Canadian hospitals, clinical (ward-based) pharmacists providing direct patient care are stretched far too thin, and there are too many hospitalized patients that have numerous drug-related problems that we do not have the manpower to tackle. We depend on research such as this, in addition to our own metrics that we cobble together to make cases for additional pharmacist resources. Shame on you Brian for not standing in solidarity with your profession.

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5 years ago

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Bryan Hayes

Steve, Thanks very much for your comments. You are absolutely right in the benefits that pharmacists provide. It has been demonstrated in ICUs, general medical wards, EDs, clinics, etc. My words on the podcast may have come out not exactly as I intended and I appreciate you pointing it out. These studies are critical to growing the profession of pharmacy. We cost a lot, and need as much justification as possible to ensure expansion in various hospital areas. In fact, I am using these same studies (and a recent one in CJEM) right now as I try to add more ED pharmacists to my team. If you don’t agree that “it is hard to justify those salaries today,” then I’d invite you to further research the healthcare system in the U.S., particularly in light of the new healthcare laws that are further reducing hospital reimbursements in all directions. Every dollar and salary is scrutinized for the hard-dollars that are saved by having that position in place. In other words, is this position somehow increasing revenue or paying for itself? Pharmacy has a difficult time demonstrating hard-dollar savings, even though we track interventions and know that we save the hospital millions… Read more »

Do you have a reference for the statement regarding an incidence rate of 75% of pts become hypoglycemic from IV bolus insulin / dextrose? We are re-evaluating our protocol in the ED and I would like some supporting literature.